By: Judith King (SA SURE Plus Copy and Content Editor)
Few among us would look forward to being pierced with a needle of any size, much less waiting for several hours at a clinic to have this done – and when this procedure is necessary to determine one's HIV status, it can be even more challenging for clients.
HIV self-testing – or HIV self-screening (HIVSS) – offers a fast, reliable and painless alternative to the fingerprick blood test. Using the OraQuick test-kit (quality-assured and approved by the National Department of Health), clients can collect their own oral-fluid sample by swabbing their gums and testing it with the kit materials, which yields a result within 20 minutes.
Health Systems Trust is supporting the introduction of HIVSS as a formal HIV Testing Services (HTS) intervention in facilities and communities, in collaboration with the Department of Health (DoH). Trained HST and DoH Lay Counsellors work from facility entry points − waiting areas or consultation rooms − in high-burden facilities to assist clients with the HIVSS process, and the service is delivered by Outreach Teams in communities.
At facilities, clients who are interested in carrying out the test immediately may do so in the Lay Counsellor's office or in pop-up tents on the clinic premises (which ensures client confidentiality during screening and interpretation of results). The Counsellors provide pre- and post-test counselling, and guidance on how to administer the test and interpret the result, whether positive or negative.
If an HIV-positive result emerges, the client is referred immediately to a nurse who assesses the person's readiness for initiation on antiretroviral therapy (ART). If the result is negative, the client is encouraged to return to the facility in six weeks' time for a confirmatory test.
The clients' contact information is recorded for follow-up phone calls and home visits, which are important for providing emotional support and ensuring that they understand the need to be re-tested and receive treatment if necessary, along with the offer of testing for partners and children.
Assisted HIVSS at Mpumuza Clinic
At Mpumuza Clinic in the uMgungundlovu District of KwaZulu-Natal Province, six HST and three DoH Lay Counsellors are instituting HIVSS for clients in the Acute, Mother and Child, and Chronic Streams. First, the Counsellors provide health education about HIVSS and the OraQuick test to promote the service. Willing clients are then ushered to one of three pop-up tents just outside the clinic building, where they can self-administer the OraQuick test under the Lay Counsellor's guidance and supervision.
Members of the HST team that assisted HIVSS at Mpumuza Clinic in uMgungundlovu
"The involvement and support of the clinic's Operational Manager has been key to securing the DoH staff's buy-in for the service," explains Palesa Jali, HST's Area Co-ordinator. "He understood that the concept enables management of approximately three client HIV tests within 30 to 40 minutes, including pre- and post-test counselling. This improves the clinic's performance towards reaching its HIV testing targets. It also shortens the clients' waiting time and helps to decongest the clinic space, which is especially important during the COVID-19 pandemic."
HIVSS pop-up tents outside the Mpumuza Clinic
HST Area Co-ordinator Palesa Jali discusses HIVSS with a client
The primary benefit of HIVSS is its patient-centred focus in enhancing access to and acceptability of HTS and linkage to care. Assisted HIVSS ensures that people in HIV high-burden populations who are undiagnosed or hard to reach – notably men and adolescents – have more options for knowing their status. In turn, this contributes to achievement of the UNAIDS global '90-90-90' and 2030 testing, treatment and viral suppression goals.
Mpumuza Clinic's Facility Team Leader, Phumzile Mtolo, confirms that although women make up the majority of the facility's HIVSS clientele, good numbers of men and young people are taking up the service. "We've found that youth in the 12- to 15-year age group and men are happy to use the OraQuick test because they can avoid the needles. Also, men prefer not to be inconvenienced, so if there is a group of male friends, they can do their own testing in the tents simultaneously and this works – they don't procrastinate."
"If the client has been well educated beforehand, it's much easier for them," adds Mtolo. "They appreciate seeing the result for themselves, whatever it may be, and accept that it's as accurate as a blood test. Those whose first results have been negative are also returning for their confirmatory tests six weeks later. The quality of pre-counselling is therefore vital because it's a new service, but if it's done correctly, people are open to it."
DoH Lay Counsellor Busiswe Mthetwa agrees. "Together with the HST teams, we support each other with implementing HIVSS, which clients love because there is no fingerprick required. Initially some don't believe that the test can be done with oral fluid, so it's very important that we relay the correct messages to them, as guided by our HIVSS training. We take care to inform clients that the OraQuick test is optional; we don't want to infringe on their rights and we must respect their decisions, although very few clients refuse this option. We listen to the clients' concerns and reassure them."
"I chose HIVSS because it's much easier in the mouth than the fingerprick," says client Nonhlanhla Nxumalo. "This is my six-week re-check, and I came back for it because there's no pain. I enjoy the pre-test counselling, as it reminds me of things I may have forgotten when the initial counselling and test were done. I did not doubt my result, as the Lay Counsellor explained everything so well."
Uptake of HIV treatment
Immediate enrolment on treatment among HIVSS clients whose result is HIV-positive is not as easy. "Many are still not ready," Mtolo says. "Last week a 15-year-old was very upset about her result, but she came back for treatment. Some refuse point blank and probably don't want to disclose, so they make excuses about having to bring their partner back with them… but the Lay Counsellor will arrange with the Index Contact Testing team to follow up with them."
HIVSS integration with index contact testing
In both facility- and community-based settings, index contact testing is an integral approach for reaching untested populations. All client interactions include an offer for the patient's partner or child to use HIVSS kits, with support for partner notification.
Re-testing in the community is also being implemented by Outreach Teams. "Our current concern is the low headcounts in the clinics because of COVID-19 and other factors like multi-month script dispensing, so we're not seeing the usual number of clients coming into the facility," says Jali. "We should see better HIVSS uptake once more clients come in, but in parallel, the Outreach and Index Contact Testing teams are finding clients for HIVSS at household level."
"The uptake of HIVSS is currently higher in facilities than in the community," notes Felicity Basson, HST's HIV Testing Services Co-ordinator for KwaZulu-Natal. "This can be attributed to HIVSS being rolled out at facilities by our staff with the support of DoH personnel, and that we cover more facilities with direct service delivery than the Outreach Teams do."
Collaborative training, tools and roll-out plans
Earlier this year, HST and the Provincial Department of Health jointly developed an HIVSS Standard Operating Procedure and screening tools, and a revision of the HTS Register to include HIVSS. Training of DoH staff on these tools will be rolled out in other HST-supported districts. Prior to the outbreak of COVID-19, HST introduced assisted HIVSS at colleges, universities, factories and farms during wellness campaigns.
"HIVSS targets will be set for all teams at facility and community level," says Basson. "We hope to leverage private pharmacies in eThekwini to supply the OraQuick test-kits, and to extend HIVSS implementation to other workplaces and truck-stops, all the while observing COVID-19 precautions."
All applications of HIVSS conform to the World Health Organization's 'Five Cs': Consent, Confidentiality, Counselling, Correct test results, and Connection.
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